National Assembly for Wales

Health and Social Care Committee

Post-legislative scrutiny of the Mental Health (Wales) Measure 2010

Evidence from Hywel Dda University Health Board – MHM 16

National Assembly for Wales Health and Social Care Committee

Post legislative scrutiny to assess the implementation and operation of the Mental Health (Wales) Measure 2010

Consultation response

Theme 1 - Assessing the extent to which the stated objectives of the Measure are being achieved.

1) Provision of Local Primary Mental Health Support Services – Part 1

The aim of these services is to improve access to mental health care within primary care settings, and to improve the outcomes for individuals accessing these services. This should be achieved by increasing the availability of mental health services in primary care and, where possible, providing support for individuals in relation to their non-medical needs (such as support in accessing employment, housing and education services). There will also be increased support for primary care providers to help them improve the health and well-being of people with mental health problems.

· Objective is being achieved but demand has exceeded expectation

· Further clarity and refining of referral processes is needed with Child and Adolescent referrals as their ‘natural’ route of the majority of referrals are from Education Services.

· There remains a continuing need to promote the Local Primary Mental Health Support Services (LPMHSS) model with GPs and the Primary Care Teams

· A recently revised LPMHSS target of 28 days first contact instead of 56 days (since 1^st April) has been challenging

· Greater joint working between Psychiatrists and Primary Care services in diagnostic advice and treatment may reduce the need for patients entering secondary mental health services.

· Joint link working between the LPMHSS clinicians and the Community Mental Health Team (CMHT) clinicians within GP practices is reaping benefits in terms of providing an actual presence and easing ‘brokerage’ process.

· Benefits and outcomes have been seen on the early recognition / early intervention / early recovery of mental health.

· Time to Change Wales has added to the opportunity to promote reduction in stigma alongside the MH Measure especially LPMHSS.

· The National Community of Practice Forum for LPMHSS is beginning to provide opportunities on identifying best practice and sharing amongst team leads to help drive and improve standards.

· Local Authority working in conjunction with partners to identify support and/or develop community based, person centred services.

2) Care and Treatment Planning – Part 2

Part 2 of the Measure requires that all people receiving secondary care mental health services in Wales receive a care and treatment plan. A care coordinator is required to produce the plan with the engagement of the service user and mental health service providers. The duty to produce outcome-focused care and treatment plans will lead to more effective and efficient service delivery, with an emphasis on the recovery of the service user. The requirement for a holistic approach to care planning spanning a range of medical, psychological, social and spiritual needs will lead to service delivery that is more comprehensive and more enabling.

· Care and Treatment Planning (CTP) is focused on a person centred approach with a progressive care plan and agreed contingency plan. This has resulted in a reduced bureaucratic approach in comparison to the previous process and therefore improved actual time with Service Users

· Targets for the number of people receiving full CTP have been consistently reached however quality outcomes remain challenging.

· Quality issues are being addressed through further training. A specific training pack has been developed for all care coordinators and will become mandatory for all new clinicians.

· A system of obtaining service user feedback on their Care and Treatment plans should perhaps be developed locally or nationally.

3) Self re-referral into Secondary Care Services – Part 3

Objective - introduces a safeguard for people who have formerly used specialist services and have been discharged. It achieves this by placing a duty on Local Health Boards and local authorities to assess whether former users of specialist care services once again need such services. It therefore removes the requirement for referral via the G.P. and allows people to refer themselves to specialist care if they believe that their mental health is deteriorating. This safeguard will remove delays in accessing specialist care and ensure a more timely response to relapse.

• Although there have been problems in measuring the performance elements of this aspect of the measure we are working towards a nationally agreed process for re-referrals and a meeting with Welsh Government and other Health Boards in August was held to progress this issue. 

4) Independent Mental Health Advocacy (IMHA) Service – Part 4

The expanded service will continue to be known as the Independent Mental Health Advocacy scheme, and will build upon the current arrangements for the provision of the service. The expanded scheme will continue to support patients under the compulsory powers of the 1983 Act (which will now include patients detained under certain short term sections), but will also act as important safeguard for patients receiving assessment or treatment for mental ill-health in hospital who have been admitted without recourse to the 1983 Act.  The expanded independent mental health advocacy scheme will provide help and support to all qualifying patients, irrespective of age or diagnosis, in relation to the care and treatment they receive for their mental disorder.

• IMHA is well established across all in patient areas both in Mental Health and Acute Hospitals and well accepted in the clinical areas
• The IMHA Service training and awareness that was invested pre implementation has reaped benefits in respect of the establishment of this approach with clinicians 

Theme 2 - Identifying whether there are any lessons which can be learned or good practice shared from the making and implementation of the Measure and the associated subordinate legislation and guidance.

• CTP training. There remains an ongoing need for a national training strategy for the ongoing establishment of CTP in the post implementation period of the Measure. This training extends to include statutory partners in the process. The Hywel Dda University Health Board CTP training package is being shared with Welsh Government.
• National forums are providing a useful resource for all Health Boards to meet and agree national standards for implementing the Measure such as  the Community of Practice Forum for LPMHSS Team leaders
• Local Authorities support the measure in a number of ways through its leisure, cultural and educational services as well as through social services and housing.

Theme 3 - assessing whether the Measure has represented, and will continue to represent, value for money

• The role of LPMHSS in screening / signposting / brokerage and therapeutic interventions provides effectiveness in maintaining mental health and preventing the need for referral to secondary mental health services. Further work is needed to determine how this can be objectively measured in cost benefit terms. This work will need to include the costs associated with delivery of targeted universal services.
• If LPMHSS are successful, will this reduce the need for secondary mental health services and will we see a shift in resources, more towards primary care? It may not see a change in numbers but when linked to the increasing population that may then demonstrate whether the measure has been successful. It is challenging to establish what costs could have been had the measure not been introduced. Would we benefit from a national or local system of analysing this?
• Mental health budgets must be ‘ringfenced’ in primary care to ensure the resources are adequate for the role.

September 2014